2025: the year in health policy and politics – with Hugh Alderwick and Rachel Sylvester

Health Foundation (2025). Dazed and confused? Policy ideas behind the 10-Year Health Plan. 

Policy Exchange (2025). The NHS – a suitable case for treatment? 

The Observer (2025). Poor families of babies brain-damaged at birth given lower payouts than richer parents. 

UK government (2025). 10-Year Health Plan for England: fit for the future. 

Health Foundation (2024). Is the grass really greener? 

Health Foundation (2024). Priorities for an AI in health care strategy. 

Health Foundation. Public perceptions of health and social care. 

Times Health Commission (2024). Times Health Commission: A report into the state of healthcare in Britain today.

UK government (2024). Plan for change: Milestones for mission-led government.

Jennifer Dixon:

Well, it's been quite a year, hasn't it? The NHS 10-year plan; mass reorganisation in the NHS; performance so-so at best; missions downgraded; the Casey review of social care beginning to be mobilised; a few more public measures in place; and a lot of ‘techno-optimism’. But is progress being made overall? 

Well, with me to assess the year, and hopefully in a festive spirit, I'm delighted to welcome Rachel Sylvester, who is Political Editor of The Observer. And welcome back to Hugh Alderwick, who is Director of Policy and Research here at the Health Foundation.

Standing back, both of you, what do you think of the last year, or indeed really, Labour since it came to power? How has it handled health, the NHS and wider public health? Is this a year to celebrate?

Hugh Alderwick:

It's funny because outside of health, it looks like it's going really well. I think there's a narrative that this is a reforming department – that they're taking on public service reform. I think the vibe inside the health system is very different. The government's got very big objectives to transform the NHS, deliver a national care service, improve the nation's health. And still, more than a year into government, it's not really adding up to a coherent programme to deliver those objectives. The waiting list is slightly better than when they came in, some of the dials are a bit better. But this is a year where we were supposed to see this big 10-year plan for reform, which we have seen but I'd say, a bit underwhelming, still a bit messy. There's some big ideas that aren't at all new, it's not clear how they'll be delivered. Resources to back it up are thin.

Social care was stuck on hold. And then the health of the nation, we've seen some drips of reasonably good policies. We saw the measures on child poverty in the Budget last week, which are good for reducing inequalities and for health. But compared to this idea we thought we were going to get going into the new government of this health mission, I think also that's been a bit missing. So some small bits of progress, but not a coherent programme.

In the meantime, structural reform in the NHS is going to waste a lot of time and distract the system from the big job. So the 10-year plan was supposed to be the big policy thing. Actually, the big policy change has been this big top-down reorganisation that Labour said they weren't going to do.

Jennifer Dixon:

So, Rachel, how is it seeming from the political perspective?

Rachel Sylvester:

If you look around the cabinet table, you've got people who are reformers and people who are much more cautious, and it's action versus angst if you like. And Wes Streeting is absolutely in the action man category on speed. He's positioned himself and he's determined to be a reformer. And I totally understand that if you're in the system, that can be discombobulating and frustrating. But actually, looking at it as a whole from the political point of view, the thing I find increasingly frustrating is the lack of reforming zeal elsewhere in government. So at least in health, there is a sense that they want to change things. Totally agree with you, social care is a complete black hole and mad to delay that as long as they are. I remember one hospital chief exec saying it's a bit like Game of Thrones at the Department of Health. It's this constant battle.

But if you compare say to education, where the curriculum and the assessment review was so cautious and incremental, and actually pathetic, at least Wes Streeting has got some ambition and wants to change things. I thought the steps in the right direction on things like the milkshake tax in the Budget.

Putting public health more centre stage than perhaps it has been; a recognition of the importance of health inequalities. And I think you're right about the child poverty, housing also I'd put into that.

Also, courage to take on the unions, which is again in contrast to the Department for Education. There is a forward motion that obviously feels disruptive if you've inside, but I think for the country you need that forward motion.

Jennifer Dixon:

So there's ambition, verve, communication skills par excellence. Wes Streeting is a strong character, isn't he? But there's still a disconnect between that slightly performative gloss and what Hugh is saying. And that is not coming across in the papers as much, is it? Certainly, the right-wing press seem to be great friends with Wes Streeting.

Hugh Alderwick:

You look at the government's 10-year plan, for example, shift to prevention, more care outside of hospital. Those things aren't very new, they're not very radical from a party sense. They've been dotted throughout NHS planning documents for a long time. The radical stuff has been shaking up the structures and the administration of the systems, scrapping NHS England, merging integrated care boards. In some sense, that's not the least bit radical either because that's just what the NHS always does, but that's highly disruptive. Maybe from the outside that looks like reforming zeal, but it's sort of just nonsense from a policy perspective. Changing the number of commissioners, merging arm’s length bodies. There's some logic to some of those changes over the long run, but I don't think they're delivering anything apart from wasted time and energy.

So I think some of the rhetoric is really big, but when you look at the policy changes, particularly on the NHS and social care, I don't think they're that radical or new. They're often in the right direction, but developing more integrated care, shifting care outside of hospitals, more integration between the NHS, social services, good things, but NHS has been at that for quite a long time and really struggled. And I think the challenge is where's mix of ingredients that mean it'll be different this time around?

Jennifer Dixon:

I suppose in his favour, they've wanted to prune regulation, which is worthwhile. He's also kicked off some safety reviews, maternity in particular, Leeds and wider maternity. But the bit that I think is not barking as much as it could be for a really reforming Secretary of State is all the technology and AI side. If you think about it, that's a big, big area of hope, isn't it?

Rachel Sylvester:

That should be the real game changer, but my impression is they are doing quite a lot actually on rolling out AI scanners, the NHS at becoming much more front door. If you compare to the way in which they've mishandled the wider digital ID card introduction, which has suddenly turned into something all about immigration rather than an enabler of government services. I think that's a far more important reform actually than the NHS England stuff, everything on technology. And more practical. And I think it is going ahead, isn't it?

Jennifer Dixon:

It is, but one example is there isn't an AI strategy at the moment. There isn't really a full-blooded how would you test AI at scale in a massive way. So I don't see that yet, and although it's written into the NHS plan with the App and the virtual hospital that was announced, all of that's good, good, good. We need some speed here, don't we?

Hugh Alderwick:

I think the policy architecture's still under construction. How do you regulate AI in health care, really knotty, challenging, technical, ethical questions. What capabilities do staff need? This is a really big shift, which does have big potential as you say, Jennifer. And some of this is just sweeping across the health system anyway. Aside from what government does, you talk to GPs who are often using some of these technologies. But there's big rhetoric from government, they want to move forward on these things, but actually it's quite tricky and complex, and very closely linked to the resources and skills staff have to improve services. And actually, some of that feels like it's being cut back and cut away, and staff are under huge pressure. And still, the basic care often doesn't work, so there's a bit of a mismatch between the rhetoric and the reality.

Jennifer Dixon:

Can I just turn to the public mood? Because I think that's always a weather vane isn't it, for how the year has gone in terms of political handling. At the Foundation, we have these rolling Ipsos polls. Can you just chart out for us, Hugh, then what the public mood is around the NHS at the moment, given all the worries about access and waiting?

Hugh Alderwick:

Overall, satisfaction with the NHS is still lowest on record. There's some small signs of progress, so a bit of an increase in people's perceptions of how easy it is to access their GP over the last year, but overall the mood is still really gloomy. Public perceptions of government policy are also poor. So we ask, ‘Do you think government has the right policies in place for the NHS?’ It was lower before the election, so it's jumped a bit. Only 16% agree that the government responsible for the NHS in their part of the UK has the right policies in place. That said, the support for the core principles, so comprehensive, free at the point of use, it's largely tax funded, that's still rock solid despite low satisfaction.

Standing back, what we see is a bit of a mismatch between political priorities and the public's priorities. So government's one big target on health, let alone the NHS, is to reduce the routine hospital waiting list or times waiting. Public, you ask them, and it's making it easier to see a GP. So given resources are so constrained, hard to meet all of these things at once over the rest of the parliament, that might become a problem. If resources that are limited are going into reducing the waiting list, really the public, of course they want to reduce the waiting list, but the top priority is to see their GP. If that gets deprioritised to funnel resources back into hospitals, then it's going to be a bit tricky I think come the election.

Jennifer Dixon:

And the figure that's quoted from the British Social Attitude Survey, which is this lowest ever figure, only 21% of people are very all quite satisfied. But the question is satisfied with the way that NHS ‘is run nowadays’. When you actually ask people not how the NHS is run, but how satisfied are you with the care you actually receive, that's so much higher, more like 51% are happy on other polls. But the satisfaction is actually much lower for GP care, 23%, or A&E care, 12%. So I think there's two things. One as a politician is how they're running, but also it's the access to care. Once they get into care, then there's a different story I think.

So, Rachel, does that chime, what Hugh's just said, with what you're picking up?

Rachel Sylvester:

If you talk to people in Labour, there's three things they'll be judged on at the next election. The cost of living, immigration, small boats, and the NHS, particularly waiting lists. And a lot of MPs actually do talk about the GP access as a big issue. So I think it's a huge priority because they feel it's a priority for the voters. And there is that sense also that if Labour doesn't fix it, then Reform will come in. Will they scrap it, will they completely tear up the foundations of the NHS? There's a huge moment of jeopardy for the NHS, so there's a big heavy responsibility for them.

So Rachel Reeves, when she was preparing her Budget back in the summer when she first told the Treasury officials what the priorities were, one of the NHS waiting lists, which meant keeping capital investment at a sensible level. So they know politically and in terms of their own survival and for the country that it's really crucial. I think for the Conservatives, it's quite interesting because they're not quite sure what to say because they've always been nervous of being seen to sell the NHS down the river. David Cameron had that whole campaign, ‘We'll cut the deficit, not the NHS,’ with his huge face over a massive poster because that was seen as a real brand issue. The trust in the NHS was so critical. So I think that public affection that, even if the scepticism about some of the access issues or some of the way in which is managed, politicians are really aware of that or feel that in their constituencies.

Jennifer Dixon:

Some of the lingo that was used in the last year, the reform or die lingo didn't really help, did it? Last chance saloon, that's the other cliché, isn't it? It sets up that if Labour can't do this, then of course the NHS has got it coming.

Hugh Alderwick:

It's an odd narrative I think. Well, it's a bit of a political gamble, I suppose. But of course, the access problems and the challenges the NHS faces, if you ask me, are not so much to do with the NHS model, it had to do with longer run challenges, investment, policy failure and a bunch of other things. And it's going to take quite a long time to bring the NHS back to, for instance, waiting times people want and they expect, to redesign services in the way government's talked about. It's more like a 10-year programme.

So government's setting up this reform or die narrative. What happens come the next election if, as it looks like, maybe they'll get close if they're lucky to meeting their waitings times target? Other improvements are going to be challenging, the budget's getting swallowed up by a bunch of other costs. Higher pay bills that might come, drugs prices, growing ageing population. Well, what's the narrative then? Things have gotten a bit better on the waiting lists, but you haven't seen this transformation, and stick with us because we're still reforming it, or is it dying? I think it's quite confusing and it leaves the door open to unhelpful narratives that focus on the wrong problem, which is the NHS model.

Rachel Sylvester:

You need the people in the NHS to deliver the care. Out of all the public services, it's the one that depends most on the people. And if you alienate the people working in the NHS by having this threatening atmosphere, that's really problematic. Michael Gove did that with the teachers at education when he talked about the blob in education. You need to be working together with the people in the NHS. But I think that's quite tricky when you've also got the unions agitating when they've got a really generous settlement compared to the other public sector workers. Then marching out again, I can see why politicians get really frustrated by that.

Jennifer Dixon:

I was just looking at the OBR, the economic and fiscal outlook as you do, this morning...

Rachel Sylvester:

I thought this was meant to be celebratory. Festive.

Jennifer Dixon:

This is not very festive, no. Well, it depends how grateful we should be for projected 1.5% growth in GDP. The NHS this year got 2.9% real-terms per annum growth for the next 3 years. So it is more generous than projected GDP growth. And then as you say, there's the strikes to settle and then there's also the pharma pricing. The tariff issue is a separate threat on top of that. So that 2.9% could easily be eaten up almost in its entirety without any modernisation going on. So how do you then square reform or die with that pipeline of money?

Hugh Alderwick:

Well, and compared to the past, as you say, so pretty generous in relative terms, but that doesn't change the need in the system or the resources you need to improve it. Lower than historical average, and much lower than last time there was a Labour government saying we're going to reform the NHS, average spending over that period each year in real times was 6.8%, so more than double growth. But that's the period where you see big targets on improving waiting times and the resources going in to do it. You've got similar rhetoric now, not similar cash.

Rachel Sylvester:

This is where technology becomes so, so important because they've just got to boost the productivity. And the only way you can square that circle of not having any money, but wanting more personalised services is through technology. And both using the data much better, using the technology more predictively, personalising the care, much more prevention. But then also, just the efficiency of the systems. So using those databases to make sure the patients flow as quickly and efficiently through the system as they can, and joining it up with social care. In a way it's lucky we're at this point now, because there are these new technologies. If they were only to embrace in full the potential, that is a way of squaring that otherwise impossible circle.

Jennifer Dixon:

It's definitely right. Although, as someone said recently, this is a socio-technical issue. So the ‘socio’ being that staff, that you have to motivate, actually have to do this and they have to really lead it.

Hugh Alderwick:

Some of these things might really improve outcomes if we're lucky and often they need to be evaluated, but they might increase costs. And probably in the short term, it's the more boring things like capital investment, new buildings, equipment, IT management that allow it to be the big drivers of productivity. Improving processes and flow through hospitals so people aren't stuck at the back end and then the beds aren't free, and people are then stuck in A&E. So agree with what you're saying, over the long run there's real potential here.

You look at the government narrative, I think it's classic demonisation of managers, admin staff in the NHS, cuts to local management bodies. Capital, yeah, there was a boost in capital in the first year, but still capital growth is relatively flat over the rest of the parliament. And that's coming after a long period of underinvestment in capital, and that's just the basics like buildings, equipment, IT, R&D compared to other European systems. So while improving productivity is the key to square that circle, some of that underlying basic factors that can improve productivity are often not in place, or they're patchy, or they need to be reconstructed, particularly after the pandemic.

Rachel Sylvester:

One of the things that was frustrating is the government somehow just doesn't see modernisation future-facing potential of a lot of these technologies. It's all about how are we going to basically curtail your civil liberties, and force you to work, and force you not to be an immigrant. It's all about being mean and nasty, rather than saying the opportunity.

And we are living at the moment also, another cause for optimism, in this extraordinary new age of cures. Where let's just not lose sight of the fact that just in terms of technology, there are incredible things coming that will enable us to be much more aware of our own health, our own risks, take much more charge of our own health, rebalance that relationship between doctor and patient. But also, these genetic cures coming where not only will they be able to treat disease, but actually cure disease and eliminate the faulty genes. That is something incredibly amazing to be celebrated. Patrick Vallance, the Science Minister, talks about this ‘new age of cures’. And I know that presents challenges, but I think there are reasons for the NHS to be optimistic about the future as well and I think it's really important not to lose sight of that.

Jennifer Dixon:

I think where the story is more positive about the technology is in the growth potential narrative, which is important for the country. It's a slightly different narrative to sustaining the NHS into the future as a universal free services at the point of use, and that yet is under-utilised I think as a narrative that could motivate staff, make your day easier, give you back the gift of time as Topple says.

Maybe that spirit swiftly brings us then to the reform, because obviously this was a capital-‘R’ reform year, at least in terms of the written word. So we had the 10-year plan in July. We had the Life Sciences Sector plan at the same time. A few months before, we had the reorganisation and the resignation of Amanda Pritchard. And then of course, the ICB restructuring as you described, regulation pruned. And as we were just beginning to talk about, some movements on technology, particularly to do with the NHS App.

Turning to Hugh, you described in your BMJ leader that the NHS 10-year plan is a bit dazed and confused with respect to how does it all gel together. It was a collection, wasn't it, of stuff?

Hugh Alderwick:

There's two tracks in parallel on NHS reform. So one track is these three shifts: more prevention, more community-based care, digital tech, and policies that might go with that. And then there's the structural reform, so scrapping, merging, changing organisations. The year was supposed to be about the first one, but I think actually it was about the second one.

On the 10-year plan, the general consensus when you speak to people and my take is that good ambitions, right direction on the whole, not much, surprisingly little given how long it'd take to write, about how it's going to be delivered and resources to make it happen thin. And when you try and work out what's the overarching idea, the guiding principles for how reform is going to work, is it competition, collaboration? It's a bit random. And worse, it maybe risks pulling in different directions. So as an example, some of the measures talk about devolving more power to the front line, but actually in reality some of the policies centralise power we've got. Talk about collaboration between different kinds of organisations to integrate services, but actually league tables, competition is back in many ways. Talk about shifting care out of hospitals, but actually hospitals seem to gain quite a lot of power through the reform measures.

And then on the structures, the decision to scrap NHS England sort of came out of nowhere, didn't it? It reflects this long run debate in the history of the NHS about how do you take the politicians out of it and at the top of government, can you split policy formulation and policy implementation? There's some logic of bringing NHS England back into the department, the experiment at putting day-to-day management more at arm’s length under the Lansley reforms didn't really work, micromanagement persisted. And oddly, NHS England under Simon Stevens sort of became this strategy headquarters. But big bang, bring it in, rather than maybe a slower incremental bringing together feels highly disruptive. Odd timing when you've got such big problems to be focused on, and really your most senior leaders in the NHS and government drawing organograms, reapplying for their jobs, instead of focusing on the reform agenda.

Jennifer Dixon:

So, Rachel, people like Hugh and I, if you take away the reorganisation, the distraction, and the costs of it, and just look at the basic imprint of the 10-year plan, in the right direction as we say, I think everyone would agree with that. What's the guiding concepts in this? And what we always want to see is something that's coherent because only then you can then build the stuff underneath it to make it happen, the incentive structures for example, how much regulation, and so on and so forth. Is there a guiding ideology? There is no such thing as Starmerism, but what is there?

Rachel Sylvester:

I think there's a real problem, which is the lack of anything on social care. Because I think to the extent that there is a guiding principle, it's moving care out of hospital, closer to people's homes, and prevention rather than cure. But that doesn't really work unless you also sort out social care because you've got so many people, a tenth of beds at least, stuck in hospital because there's nowhere for them to go. So you can't have as your guiding principle closer to home and in the community if you don't also sort out social care.

Then I do think there's probably a live debate going on in the government about whether they can accelerate the Louise Casey review. There is an acknowledgement that that can't just drift actually. And unless you sort that, that's a huge missing piece of the jigsaw puzzle. And I think maybe that's why the rest of it doesn't quite hang together, because it's got a big black hole at the centre of it.

Jennifer Dixon:

Yes. I suppose what we're talking about is a left-right narrative to help to shape the public sector. Should there be more competition and choice? Should there be more private insurance if the NHS slides? Should you allow the middle classes to pay more in the NHS? Should you, should you, should you?

Hugh Alderwick:

And what's the role of the state? Was it mission-led government at the beginning that disappeared? We've had these targets that have changed, it's been really hard to keep track, talking not just on health now. I thought the Budget last week was interesting because there's the section on scrapping the two child limit felt more, this is our political judgement , but at least there's an idea, it's a political decision, we're backing it, we're doing it. It's expensive, but it's a highly cost-effective way to quickly reduce child poverty. That stood out because it's not usually how this government is operating and communicating. It feels far more short term, far more tactical, far more driven by the polls, iterative, responding to the agenda from Reform or from the media, whereas that felt rooted in something more core and fundamental about political values.

Rachel Sylvester:

I think there isn't a guiding star from the centre for sure. I think my impression from the Department of Health is that it is more focused on the choice. If you look at the league tables, there is a bit more of a desire to give power to patients in quite marked contrast to the Department for Education, where they're moving away from the academy freedoms and that kind of thing. So I think that's how they would define it, but there may be inconsistencies within that for all kinds of reasons.

Hugh Alderwick:

I think that's right. I think the big agenda’s back to the 2000s. Alan Milburn, an imprint on this stuff, league tables, more choice. That's at the same time as, okay, we also have a system over the last decade that tried to improve collaboration, bring organisations closer together, integration, removing some of the competition, market-style mechanism from the health system. You've still got some of those things thrown in there. The big agenda really, from a service change perspective, is getting organisations to collaborate more outside of hospital.

Jennifer Dixon:

So if the current government seems to be having a heterogeneous approach, let's put it that way, are we seeing any more clarity in any of the other parties do you think? We referred earlier, I think it was you, Rachel, to Reform or the Greens and the Tories. Peering through the fog, what are you seeing? What do you anticipate?

Rachel Sylvester:

Well, Nigel Farage has talked admiringly about French social insurance system and how we need to look at those kind of models. But whenever he's pressed on it, he backs away. And I think he realises that that may be what he believes, but actually it's not what his voters want. And there is, as your polling shows, huge public support for the NHS as a free at the point of use model. And I think that will be something that Labour really try and press Reform on in the run up to the election, really try and pin on them that they want to ‘privatise the NHS’. And that's why I think you won't see from Labour anything that could be creating a two-tier system. And I think they'll want to keep away from that to make it a clear dividing line.

There was a really interesting example actually that I came across where I was writing about maternity care and failings in maternity care. And when something goes wrong and a child is brain damaged at birth, there's a differential in the payouts depending on the income of the parents. So richer parents get a bigger payout because the system judges that the potential lifetime earnings of that baby who's been brain damaged would have been higher on average than the potential lifetime earnings of a more disadvantaged child. Which is quite shocking when you think about it. But what was interesting to me in this context is I mentioned it to Wes Streeting's team and when he was told about it, he was absolutely furious and immediately said he was going to sort this out. ‘This was appalling,’ his jaw dropped, he tweeted out the story. Any sense that somebody richer can get a better deal from the NHS I think is anathema to Labour, and particularly important for them because of the need to differentiate with Reform in this area.

Jennifer Dixon:

And what about the Greens or the Lib Dems? Lib Dems would always be very positive about the NHS I'm guessing.

Rachel Sylvester:

Because of Ed Davey's son, they've got a very strong line particularly on social care. He's got a severely disabled son who he and his wife care for, so he personally cares a lot about social care. And they've pushed that very hard and I think will continue to do so. Which makes it quite interesting, if you do start having cross-party talks on social care because if you get at the beginnings of some kind of Lib-Lab coalition pact going on, and I don't know where the conservatives and reform wound end up on that.

Jennifer Dixon:

And I don't know if you saw, there was a Policy Exchange report on the future of the NHS. They basically said we need to institute the Dutch reforms here. We need to have a Dutch system, more or less. I'm paraphrasing, sorry, Policy Exchange. And I interviewed Sajid Javid on this podcast and to have him sort of defend it, which wasn't really defensible because they spend a lot more money and put up taxes. So you think that is just going to be a nonstarter for Reform?

Rachel Sylvester:

When we looked at this when I was doing the Times Health Commission, and in fact drawing on Health Foundation research, if you look at all the models around the world, actually the type of model you use doesn't matter as much as how you implement that model. So it's blind alley and I think it's possible the Conservatives go there. But in terms of the country, I think anything that people think is going to be undermining that principle of free at the point of use would be really unpopular.

Jennifer Dixon:

Particularly as the public seems to be rock solid on that.

Hugh Alderwick:

Exactly. And I think that, as you say, Rachel, Reform don't seem to be standing behind that at the moment in terms of their policy platform. I think there's three or four reasons why it would be such a bad idea to switch to a social insurance style. The first is when you actually look at these models, they're shaped by culture, history, values. It's really hard to compare the model because it's countries that have evolved in very different ways. But when you try to, actually the distinction between a Beveridge tax-funded and the Bismarck social insurance style system is blurred over time. These Bismarck systems increasingly rely on additional government revenue from tax.

But then second, even when you try and look at which performs better, as you say, Rachel, there's no good evidence one systematically performs better than another. The third reason, as you say, Jennifer, the public, right behind the core principles of the NHS, and our model when you compare it is an efficient, fair way of raising revenue with low admin costs.

And then the fourth obvious one is switching would be a huge undertaking. It's a monumental waste of time and money. I think more likely is user charges emerges as the debate. So not switch the whole model, and of course we have some user charges, that's a feature of Beveridge, Bismarck, and hybrid system. Should more people contribute for a GP appointment, for hospital admission, for other things, or should we reduce the scope of the NHS offer? Again, we know that user charges do reduce demand for health services, but the poorest and the sickest patients suffer most as a result, so not a good idea either. But I think that's more likely to creep in.

Rachel Sylvester:

I went to Ireland to look at, they charge for GPs and A&E visits, and there's one interview that really stuck in my mind. It was a doctor talking about how she'd met a patient who had a sick 16-year-old child, basically put off taking the child to the GP, and then the boy ended up getting severely ill, hospitalised. The whole thing cost way more actually to the taxpayer because it hadn't been dealt with. And this wasn't somebody who was poor enough to be exempt from the charge, but nor was she rich enough to be able to easily afford it. To me, that was just such a compelling argument against it.

Hugh Alderwick:

I think a more honest, but also more potentially challenging conversation is what's the NHS offer? We don't have a clearly defined benefits package in the NHS, some other countries do, there's arguments for and against. But a discussion politically about what can we fund with the resources available. If the economy keeps growing at a sluggish rate, if our debt interest is still high, if we want to keep spending more on defense, the amount available for health care versus other public services which have a substantial need too is growing to grow at a lower rate than it has done historically. And the way we ration at the moment is often delay and waiting lists grow longer, but we could make some more explicit judgments that would be really difficult, but you could have a more open public debate about. So that might be a way at getting at this question, which is really about what you do if the resources available can't meet the growing demand.

Jennifer Dixon:

I do have a couple of last questions. What hasn't been done is all the policies or initiatives that have tried to strengthen public health, and there have been quite a few actually in the last year or so, as well as a Budget increase for public health. So you've got the vapes bill going through, you've got the ban on high energy in caffeine drinks to under 16 that's being consulted on, you've got the junk food advertising implementation, although that's been delayed until January. And you've got the ban on multi-buy or was it bulk offers Boris Johnson used to call it, of unhealthy food from large outlets. And quite a lot of discussions on obesity. So dispelling the nanny state, yes. Do you think that adds up to a lot, or do you think it's still quite tentative?

Rachel Sylvester:

I think it could be more ambitious to be totally honest. I think they're starting, but I think given the scale of the problem, it's not ambitious enough. There's a nervousness in government about, given the cost of living crisis, how much can we do anything that will look like we're pushing the price up of any kind of food, even unhealthy food. I also think there's a bit of a feeling that are the obesity jokes the get out of jail free card, that jabs for fitness rather than actually encouraging people to be healthier. And you look at other countries and how they really have changed their public health and obesity levels, and it's very unambitious what we're looking at at the moment.

Jennifer Dixon:

Has anyone turned the dial on obesity internationally?

Rachel Sylvester:

Fascinating, in Finland, they had some of the worst heart problem rates in the world in North Karelia. And this man came in called Pekka Puska, who instituted this programme, he called it Everything Everywhere All at Once. They created cycle paths. He had these women's institutes meetings, equivalent of where they taught them how to make healthier food. And they dramatically turned around both the obesity rates and the health outcomes starting in North Karelia, but then he moved across the whole country. It shows that you can do it.

I went to Japan for the Health Commission and they have a whole culture where employers are much more engaged in their employees' health. They even have a rule where you have to measure your employees' waists once a year to make sure they're not too fat, which I think is probably going a bit too far. They really do. It's a law. But there's a sense of the whole of society pulling together to deal with what is a massive problem and their obesity rates are going up a tiny bit, but they have had nothing like us. The lowest in the world.

Hugh Alderwick:

I think there's been there's been some good bits, extending the soft drinks industry levy. The measures on child poverty last week, really positive, but it hardly adds up to this ambitious cross-government strategy for improving health, reducing inequalities that we sort of thought the health mission was going to be on in some areas. You read the 10-year plan, actually the bit on prevention when it comes to public health is flimsy, particularly some risk factors like alcohol is not much at all. Some policies from other countries, like minimum unit pricing in Scotland, population-level measures that have a big impact, but also help reduce inequalities. They're not being considered at the moment, so compared to last time England had a health inequality strategy in the 2000s where there was investment, big targets, accountability for both central and local governments to deliver them, investment in public services, things like Sure Start.

Jennifer Dixon:

Yes, a monitoring system. Wasn't there a report to parliament on the impact?

Hugh Alderwick:

Totally. You look at the policy documents from that period, there's a huge amount of energy and effort in government on these things that you don't see now. So I think really disappointing to be honest, on health and inequalities, but we really need a modern health inequality strategy. Otherwise, things might pull in different directions. How do you hold government to account, and what are the targets across different departments that we're all collectively aiming for? Without that, I think really it'll go back to the waiting lists, the NHS. That's the health mission at the moment really is the NHS.

Jennifer Dixon:

I'm going to finish on a really unfair question. So you're in charge, you're the Secretary of State for Health, both of you. There are three big things you can push on next year in the health and the NHS sphere, and indeed social care. So what would you be saying to your officials that you really want to prioritise, these three things?

Hugh Alderwick:

The first one is I would bring forward plans on social care reform. I think it's shameful that we've got this threadbare safety net system that needs reform. So I'd say bring something forward, particularly also principally ahead of the election, on social care, even if it's setting a long-term vision.

Second, I'd go really hard on plans around supporting, strengthening primary care at services outside of hospital. That link to the agenda on AI technology, so I'd put all my weight behind constructing a really good national policy programme on implementation of more integrated service outside of hospital. Evaluate it, put money into it, show it works.

And the third, I'd try and shift the narrative and the vibe of reform to be more about supporting staff to improve and innovate locally, and giving them the resources and capabilities to do it. Not league tables, competition. This reform agenda at the moment doesn't really look like it adds up. How do we as central government give staff the support, the skills, the resources to make change happen? Because that's where it's going to happen, not in Wes's office, however brilliant he is.

Rachel Sylvester:

I would agree on social care, it's probably my number one priority. If you think about it, the worst possible thing for the government is to come up with a plan in 2028, the year before a general election, and then go into an election with something that's going to be described as a ‘death tax’, so they should do it much more quickly. And the NHS is never going to be solved without a solution to social care.

And then I would do much, much more with enthusiasm and excitement on technology. And really go for encouraging people as individuals to use technology for their health, but also encouraging professionals, liberating professionals to have more time for care, liberating patients from doctor-patient figure of authority thing. And also, using the data for life sciences and new age of cures.

And then thirdly, go all guns blazing on obesity, everything everywhere all at once. And that's not only good for health, that's good for the economy because we've got ridiculous levels of inactivity. And get the country back on its feet, literally and metaphorically.

Hugh Alderwick:

We should add, we're talking about just then, do something big on health and inequalities, develop a strategy. That's got to be some unifying goal. If they don't do that soon, then it's going too late, isn't it?

Jennifer Dixon:

So we must leave it there. Many thanks to my guests Rachel and Hugh. My insights from them were that it was a so-so year, big plans, but less delivery. But a lot of anticipation about technology, which hopefully can help. And I thought they were in agreement on the priorities for next year, social care, primary care and tech, and obesity. 

So join us in January when we'll be digging deep into what really is the public mood on the National Health Service, and also the mood across different political parties on the NHS as they begin to think up their manifestos for the next election. But until then, have a very happy Christmas and downtime to all of you, from Sean, Leo, and myself at the Health Foundation, and from Paddy and his team at Malt Films. Very much looking forward to resuming all things health with you in the new year because there will be a lot of cud to chew together. Bye for now.